Abbreviations: ECG, Electrocardiography; S, Interectopic sinus beats; n, Any positive integer
Anxiety disorders may be due to sympathetic over activity, which plays a pivotal role in electrocardiographic changes. Anxiety induced- quadrigeminy might develop in normal person rather than sick one. Patient re-assurance is considered the main way of management.
2. Case presentation
A 28-year-old married Egyptian male worker presented to hospital for regular check up. Depending on the patient history, he rarely complained of palpitation in the past. He confirmed that he isn't anxious about it. Once the ECG leads were connected to the patient, he developed anxiety. The patient denied any history of cigarette smoking, drugs or any special diet/habit. In addition, the patient denied any past history of cardiac, thyroid, or other relevant diseases. Absence of both psychiatric problems and exhaustion were also confirmed. Good sleep and comfortable daily activities were essential points in the patient's past history.
Upon examination, the patient was conscious, alert and attentive. His vital signs were as follows: blood pressure 130/70 mmHg, pulse rate 85 bpm, and temperature 36.8 °C. He has good body built with no signs of cardiac and thyroid disease. No more relevant clinical data were noted during clinical examination.
The operator explained the procedure and its safety to the patient. Once the patient was connected to the ECG machine, the patient informed us that, he is afraid and anxious because of the ECG electricity. He said that: “I am afraid of the electricity shock because of the ECG machine”.
During that time of patient anxiety, the ECG recordings were showing quadrigeminy through all ECG leads (Fig. 1).
While the patient was still connected to the ECG, the operator re-advised him to calm down and re-explained the procedure to him. ECG recordings were taken one minute later and were completely normal (Fig. 2). Patient pulse during the first ECG showed irregular regularity during patient's anxiety. While, pulse examination was completely regular during the second ECG.
Differential diagnoses: The most suitable differential diagnoses for quadrigeminy is a concealed bigeminy. [omitted sentence]. Concealed bigeminy is a recurrent unifocal extrasystoles separated from one another by an odd number of normally conducted sinus beats (S) . Odd or even numbers of interectopic sinus beats (S) in long electrocardiographic strips are essential for both analysis and differentiation.
The following equations are used to analyze the rhythm of concealed bigeminy: (S = 2n - 1) or quadrigeminy: (S = 4n - 1), where n is any positive integer, S is numbers of interectopic sinus beats .
Such patients require more investigations in order to exclude other disorders. These investigations include: electrolytes profile, thyroid function tests, full blood picture, kidney function tests and echocardiography. All results of required investigations were normal.
Patient left the hospital after reassurance.
Quadrigeminy means a cardiac arrhythmia in which every fourth beat is a premature ventricular contraction (extrasystole) or three sinus beats between extrasystoles . It is an uncommon form of premature ventricular contraction. Premature ventricular contractions are characterized by premature and bizarre shaped QRS complexes that are unusually long (typically > 120 msec) and appear wide on the electrocardiogram. The QRS complexes are not preceded by a P wave, and the T wave is usually large and oriented in a direction opposite the major deflection of the QRS . The clinical significance of premature ventricular contractions depends on their frequency, complexity, and hemodynamic response . Premature ventricular contractions occurring in young, healthy patients without underlying structural heart disease are usually not associated with any increased mortality. Patients are usually asymptomatic .Ventricular extrasystoles are common and almost always benign in the context of the structurally normal heart [4,5].
Anxiety is a subjective feeling of unease, discomfort, apprehension or fearful concern accompanied by a host of autonomic and somatic manifestations . Anxiety is a universal and generally adaptive response to a threat, but in certain circumstances it can become maladaptive .
The sympathetic nervous system mediates the symptoms of anxiety . Increased sympathetic activity may be implicated in pathogenesis of anxiety. Electrophysiology studies have shown that ventricular premature beats increase with stimulation from certain psychological stressors and decrease with a reduction in sympathetic neural inputs .
A premature ventricular contraction is caused by an ectopic cardiac pacemaker located in the ventricle. Suggested pathophysiological mechanisms for premature ventricular contractions are reentry, triggered activity, and enhanced automaticity . Factors that increase the risk of premature ventricular contractions include: male sex, advanced age, african american race, hypertension and underlying ischemic heart disease, a bundle-branch block on 12-lead ECG, hypomagnesemia, and hypokalemia. The causes of premature ventricular contractions include the followings: Acute myocardial infarction, myocardial ischemia, myocarditis, cardiomyopathy, myocardial contusion, mitral valve prolapse, hypoxia and/or hypercapnia, digoxin, sympathomimetics, tricyclic antidepressants, aminophylline, caffeine, cocaine, amphetamines, alcohol, tobacco, hypomagnesemia,hypokalemia andhypercalcemia .
Required workup for premature ventricular contraction include: potassium levels, magnesium level, electrocardiography and echocardiography . The optimal indications for therapy for premature ventricular contractions have not yet been elucidated .
By re-assurance, and sitting calm, analyzing and taking appropriate action, one can convert bad stress (distress) into good stress (eustress) . Mandrola have enumerated ten treatment steps for benign premature ventricular contraction. He had built the first 1–4 steps on re-assurance. Removing fear is always a good first step . Beta-blocker therapy is considered the first-line treatment for symptomatic patients .
- Not all premature ventricular contractions (quadrigeminy) are considered a pathological finding in ECG recordings.
- Anxiety disorders may be due to sympathetic over activity that can induce quadrigeminy.
- Patient re-assurance is the main line of treatment in absence of cardiac or relevant disorders.
- After exclusion of underling pathology, introduction of any medical interference should be avoided until effective re-assurance takes place.
Manuscript was edited by Osama Maria, MD PhD and Ahmed Alghobary, B.sc. who help me in planning of figures.
Conflicts of interest
There are no conflicts of interest.
 Levy MN, Adler DS, Levy JR. Three variants of concealed bigeminy. Circulation. 1975 Apr;51(4):646-655. PMID:46794.
 Kerin N, Mori I, Levy MN. Ventricular Quadrigeminy as a Manifestation of Concealed Bigeminy. Circulation 1975 Dec;52:1023-1029. PMID: 52413.
 James E Keany, Erik D Schraga. Premature Ventricular Contraction Treatment & Management. Updated: Jan 13, 2017. http://emedicine.medscape.com/article/761148-treatment
 Steve Goodacre, Karen McLeod. Extrasystoles, Abnormalities of rate and rhythm, Paediatric electrocardiography, ABC of Clinical Electrocardiography, BMJ Publishing Group. First edition, 2003;(15)57-60. ISBN 0 72791536 3.
 John Mandrola. Benign PVCs: a heart rhythm doctor's approach. cardiac electrophysiologist, cyclist, learner, June 2, 2013 By Dr John. http://www.drjohnm.org/2013/06/benign-pvcs-a-heart-rhythm-doctors-approach/
 Richa Shri. Anxiety: Causes and Management. J Behav Sci 201;5(1):100-118. ISSN:1406-4675
 Shiri M, Akhavan S, Geramian N. Anxiety Disorder and Its Types, Essential Notes in Psychiatry, Dr. Victor Olisah (Ed.), 2012;5:87-116. ISBN: 978-953-51-0574-9, Publisher InTech.
 Freitas-Ferrari MC, Hallak JE, Trzesniak C, Filho AS, Machado-de-Sousa JP, Chagas MH. Neuroimaging in social anxiety disorder: a systematic review of the literature. Prog Neuropsychopharmacol Biol Psychiatry 2010 May 30. 34(4):565-80. ISSN: 1878-4216 [Medline].
 Jiang Wei, Kuchibhatla Maragatha, Cuffe Michael S, Christopher Eric J, Jude Alexander D, Clary Greg L, et al. Prognostic Value of Anxiety and Depression in Patients With Chronic Heart Failure. Circulation 2004;110:3452-3456. doi: https://doi.org/10.1161/01.CIR.0000148138.25157.F9
 Pothuri Radha Krishna Murthy. Hypertension, Heart in Fours: Cardiology for Residents and Practitioners, Third Edition: Jaypee Brothers Medical Publishers (P) Ltd. 2013;(B):54-120. ISBN 978-93-5090-493-0